The Right Sort of Confidence - (Easter Egg: Acute abdominal pain in children)

I feel pretty confident that my car has the right amount of oil in the engine and air in the tires.  Why?  because that has been the case every time I check these things.  So why bother checking?

Paediatrics is a dangerous speciality because the usual outcome of any child presenting for assessment is that everything is fine.  Fever?  It's probably an uncomplicated viral infection.  Rash?  Virus.  Lump in the neck?  Virus.  You get the idea.

As a result, any one of us can become so used to the benign outcome that we don't expect the dangerous problems or the unusual causes of childhood symptoms.  This is called availability bias.  The last 50 children with this presenting complaint had a virus and got better, so this patient is likely to be the same.

Of course the statement about the likelihood is true, however people don't bring their children to us just for a probability estimate.  We are there to assess whether there is a significant problem that requires intervention.  To get there, we need to know what to look for.

Abdominal pain in children is a good example.  Children often get abdominal pains.  One of the most common presentations is abdominal pain during a febrile illness.  Most likely cause?  Virus.  I suspect that the significant pathology that is most often considered in this situation is appendicitis.  Appendicitis is relatively rare in younger children but paradoxically more difficult to diagnose, so while the chances of a 3 year old having appendicitis is very low, so are the chances that a 3 year old with appendicitis will get this diagnosed easily.

Appendicitis is at least on our minds and so we're probably not going to miss it through failure to look.  There are plenty of causes of abdominal pain that are easily missed for various reasons.  Lower lobe pneumonia, for example, is easily missed because it isn't in the abdomen.  Testicular torsion is easily missed if it isn't looked for.  You'd think that if a child or young person had a problem with their genitalia they might mention that.  They often don't.  If you don't look for torsion, you won't find it.

Here's a brief overview of some of the easily missed causes of abdominal pain in children:

Here is a more extensive list of possible causes of abdominal pain in children. (1)

Going through these, starting at one o'clock:

Mesenteric Adenitis - Yes, children with viral upper respiratory tract infection can get acute abdominal pains and can even have localised abdominal tenderness.  Children with more significant causes of pain can also have URTI, so if there are red flag signs or symptoms you should still take these seriously.
Non-IgE food allergy - This can cause acute abdominal pain but paradoxically is a diagnosis best not made acutely.  History, a food diary and follow-up are the way forward when food allergy becomes a possibility.
Gastroenteritis - When vomiting precedes abdominal pain then this makes gastroenteritis more likely.  Similarly, diarrhoea is a strong indicator of viral enteritis.  However, there is no such thing as always, so careful abdominal examination is key and signs that suggest a surgical cause should still lead to referral.
Gynaecological - The main thing to say about this is that it is a common pitfall to forget to even consider this possibility in children.  How often do you think ectopic pregnancy is considered in the differential of a 13 year old with acute abdominal pain?  It should always be remembered as a possiblity.  Do a pregnancy test.
Constipation - This is possibly the most common cause of afebrile acute abdominal pain in children.  There are two main pitfalls.  The first is to miss the diagnosis because the child or parent doesn't think the child is constipated.  The second is to think that because the presentation is acute, the problem just needs a brief period of treatment.  If they are constipated enough to present with acute pain, the problem is chronic and should be treated as such as per NICE guidelines.
Urinary Tract Infection - Abdominal pain +/- vomiting without diarrhoea is a common way for children to present with UTI.  There is no absolute rule on when and when not to test a urine but it is fair to say that significant diarrhoea usually precludes it for a couple of reasons.  In all other cases of acute abdominal pain, it is usually a good idea even if interpreting the result is not completely straightforward.
Colic - Truly a diagnosis of exclusion, but this can be a good history and examination. What to do with colic is covered here.
Appendicitis - Uncommon but not so rare that you won't see a case every now and then. Picking them out from the crowd can be difficult.  Good simple analgesia and reassessment after an hour is often a helpful discriminator for the grey cases if you can do that.
Testicular torsion - Inguinal and genital examination is part of the examination of a male presenting with abdominal pain.  Do it, even if the last 100 times were normal.
Intussusception - Rare but deadly.  Episodes of pallor and signs of being significantly unwell are reasons to suspect intussusception.  Bloody and mucousy (recurrent jelly-like) stools make it easier to diagnose but may be a late sign.
Diabetic Ketoacidosis - It is very easy to see how first presentations are initially diagnosed as viral illnesses.  If you've got a child who's a bit more lethargic or subdued than your typical gastroenteritis case, or if there is a report of polyuria, test a glucose.

In most cases, significant causes will be excluded by a thorough history and examination.  Often a urine test is a good idea and sometimes a second opinion will be necessary.  Abdominal X-ray is almost never useful in making a decision about referral.

Paradoxically,  the wrong sort of confidence comes from repeated experience of nothing bad happening.  The right sort of confidence comes from knowing that bad things will happen and knowing that we're ready for that eventuality.  This often happens once you've experienced the sharp end of an unexpected diagnosis.  If that has happened, congratulations!  You're now an expert.

Edward Snelson
Experienced if not Expert
@sailordoctor

Disclaimer - Experience doesn't always lead to expertise but it's a fairly important element. Bad experience is a good wad to develop great expertise but only if you have all the right elements in place to ensure that you learn without becoming a second victim.  I would like to see more work in that area, especially at the Primary/ Secondary Care interface.

Reference

1. The Essential Clinical Handbook of Common Paediatric Cases, Edward Snelson

Gastroenteritis in Children - Ten Myths

Vomiting and diarrhoea in children is usually caused by viral gastroenteritis.  There are lots of myths surrounding gastroenteritis and how best to manage it.  I find myself repeating things that I was once told years ago and have to check from time to time whether the 'fact' is in fact based in any reality.  When I find out that it was all a myth, it makes me feel so much better when I later hear other people who hold those same myths to be true.  Hopefully, between us we can dispel a few of them.  Here are a few non-truths that I regularly come across:

1.  It's just a virus.  I know that I said it is usually a viral infection in children and that is true.  However that should not fool people into thinking that it is a benign illness.  Even in well nourished children, dehydration is a real risk and every year previously healthy children with gastroenteritis suffer renal failure and other consequences of severe dehydration.  Avoiding dehydration makes for most of the dos and don'ts of gastroenteritis.

2.  Paracetamol should be avoided because it makes the child vomit.  Not so.  What is more nauseating: 5 mls of liquid vitamin P or fever and abdominal pain?  Giving paracetamol is likely to help resolve the vomiting and make the child feel more like they could cope with drinking a few sips of water.  Certainly, children often do vomit shortly after being give paracetamol but when it works, it is well worth it.

3. You shouldn't give milk to children who are vomiting.  The best fluid depends on two factors.  One factor is the level of hydration.  If a child is at risk of or is becoming dehydrated then oral rehydration fluid (ORF) is recommended.  The second factor is the question of what the child will take.  Oral rehydration is really important, so better a bottle of milk that is drunk than a bottle of ORF that is continually refused.  The important thing to avoid is the list of drinks that will make matters worse.  Milk is not on that list.  Just because milky vomit is nasty compared to when the child is drinking clear fluids doesn't mean you should avoid milk if that is what they will take.  Milk contains carbs and electrolytes and for babies it is the fluid of choice.

4.  Flat cola is great for rehydration.  What makes a poor rehyration fluid?  Acidity to worsen gastritis as well as hyperosmolality and added chemicals that will drive diarrhoea.  Flat cola ticks all of these boxes which is why it gets a special mention in the 'don't do it' bit of the NICE guidelines for gastroenteritis in the under five year olds. (1)

5.  You can't give antiemetics to children.  Now we are getting into more controversial territory.  Antiemetics such as prochorperazine and metoclopramide (where would I have been as a house officer without these two drugs?) are traditionally avoided in ill children due to the risk of dystonic reactions.  It has threfore been the case that gastroenteritis has always been in that category of illnesses that just has to get better on its own.  That may be why the world of paediatrics has failed to reconsider this view despite the appearance of newer and safer antiemetics.  There is good evidence for example that ondansetron reduces vomiting and may aid rehydration (2).  So why don't we use that when a child is failing to rehydrate orally?  NICE considered this when writing its guideline and noted that ondansetron is also associated with increased diarrhoea.  The answer was therefore that it could not yet be recommended, but possibly with more research, ondansetron will be recommended in specific circumstances.

6. You can't give antidiarrhoeals to children.  Again, NICE considered the pros and cons of this option.  There are various types of antidiarrhoeal medicines, each of which was decided against in turn, mostly on the basis that there was no evidence for benefit.  In the case of loperamide, there is reasonable evidence that it does help (3).  So what's the problem?  Loperamide is not licensed for use in children in the UK (and I think the same is true in the USA and Australia but I'm not sure about elsewhere).  However, the BNFc does list doses and acknowledges the license issue.  I don't intend to medicalise self limiting gastroenteritis, but if I thought it would help, it is good to know that it is therapeutic option.

7.  A period of starvation can resolve vomiting or diarrhoea.  The only clinical value to an enforced period of starvation for a child is that it is a great way to diagnose MCADD.  Witholding food or drink will not change the course of viral gastroenteritis.  However, some children do have underlying, yet hidden metabolic disorders of energy production.  These children have often had no manifestaion of their disorder because they have never run out of immediately available energy.  When they are unwell and rely on ketones, everything goes wrong and hypogylcaemia can come on profoundly and unexpectedly early into a period of fasting.  Any ill child who is not getting calories and who becomes subdued or agitated should have a blood glucose checked.

8.  It's a 24 hr bug.  In fact who knows how long it will last.  I don't believe that you can make something go wrong just by saying a thing.  For example, I am very happy to walk around at work commenting on how lovely and quite it is and enjoy seeing the superstitious flinch at this.  However predicting the length of a gastroenteritis is a recipe for perplexed parents.  Vomiting usually settles by day 3 and diarrhoea should be at least much improved by day 7.  Should be...
If diarrhoea is not resolving at day 7 then consider doing a stool sample.

9.  It's probably food poisoning.  Thankfully not.  The vast majority of vomiting and diarrhoea in children is viral gastroenteritis.  Bacterial infections are more likely if the child has been to an area with endemic infection.  A history of consuming foods that are likely to have been contaminated is also important.  A sudden onset of vomiting does not imply food poisoning though.  Norovirus for example typically causes sudden and severe symptoms.

10.  Dehydration requires intravenous fluids.  Rehydration is best provided through the gut, not a vein.  Although guidelines are changing in order to avoid dangerously hypotonic fluids, intravenous rehydration will always be risky.  Every effort should be made to achieve oral hydration.  If this fails then nasogastric rehydration has a good evidence base.

Of course these are only the myths that I used to believe before my faith was destroyed by reasoning and evidence.  Do you have any of your own?  If you know of a wrong but popularly held belief to do with gastroenteritis then please post it in the comments below.  Cheers!

Edward Snelson
Grade 'O' in Care of Magical Creatures at O.W.L.
@sailordoctor

Disclaimer: It feels a bit strange to be in agreement with so much of a NICE guideline.  I may be coming down with something.

References

1. Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management NICE guidelines [CG84]
2. Szajewska H et al., Meta-analysis: ondansetron for vomiting in acute gastroenteritis in children, Aliment Pharmacol Ther. 2007 Feb 15;25(4):393-400.
3. ST Li et al., Loperamide therapy for acute diarrhea in children: systematic review and meta-analysis, Database of Abstracts of Reviews of Effects (DARE)

Assessing Pain in Children - How Green Was Your Valley?

What is the best approach the assessment of pain in a child?  That is a big can of worms.  We want to understand the pain so that we can treat both the pain and the underlying cause but much of what we do comes from adult practice.  Rethinking our approach requires an understanding of what pain is to a child.  Pain is a very different thing for a child and so our approach must also be different.

Pain is an abstract thing, and the younger the child, the less abstract their thinking is. 

The internet has plenty of comical examples of things that children have written or said that are reminiscent of the story of the Emperor’s New Clothes.  In fact one of the most endearing things about children is the way that they often combine straight talking with unspeakable truths.  The ability to think abstractly and interpret what someone means (rather than what they are saying) develops as children grow.  We tend to develop what is needed for these situations based on experience of past events. To give you an example of adult thinking, I give you this excerpt, involving a word game, taken from a radio comedy with Benedict Cumberbatch and Roger Allam.  I think that this is a great example of how adults use words in bizarre ways and still manage to make sense.

Why does this word play make sense to any of us?  Years of having our minds messed with is the only answer that I can suggest.  Expressing feelings like pain relies on similar processes to that of understanding complicated jokes.

In order to account for these difficulties, some people adopt a standardised approach that allows children to choose how they express the magnitude of their pain.  I carry a card with the Wong-Baker faces (pictures of faces that go from smiley to sad)  and, if appropriate, ask the child to use the faces, words or numbers to say how bad their pain is.  My experience is that even this seemingly child friendly approach gives us the illusion that we are getting a meaningful answer because I am effectively speaking a different language.

When we are asking children about pain, how can we expect them to respond if they have not experienced that feeling before and lack the ability to describe it?  Imagine a nine year old presenting with abdominal pain.  All of the following questions are commonly asked of children in that assessment.  The responses are all real as well.  What I have taken the liberty to add is the internal response (I) that the child is having in their head.

Q. What does your pain feel like?  Is it sharp, burning, aching or colicky?

I. It feels bad.  Burning feels bad.  May be that’s the right answer. Someone called it tummy ache.  That must be it.  Aching.  If I say aching, the doctor will stop looking at me like that.

A. Aching I guess

Q. Does your pain come and go?

I. It hurts now.  It hurt yesterday. I’m not sure what the doctor means.  Why is the doctor still looking at me?

A. (Shoulder shrug)

Q. How bad is your pain? We use these numbers and faces here to help you chose an answer. (Shows Wong Baker Faces scale)

I. What is with all these questions?  Bad is bad.  My tummy hurts and it feels bad.  That’s not one of the choices on the list.  ‘Hurts more’ is there though and my tummy has definitely got worse while I’ve been sat here.

A. Points to ‘Hurts a lot more’ (6/10 on Wong Baker scale)

So what should we be doing?  I am not saying that questions or pain assessment tools are unhelpful, just that they should not be applied unthinkingly.  The trouble is that the child wants to give you an answer.  I think that sometimes they want to give an answer so much that they might give one for the sake of giving an answer. I think that there are two simple things that do work really well with children.

1. Just ask them what their pain is like.  A nice open question will tell you one of two things.  Either the child will describe their pain in a way that makes sense to them or they will make it obvious that they don’t really understand how to describe their pain.  Having no answer is better than a forced answer.  If they seem able to begin to describe their pain, you can progress to more closed questions and a scoring system perhaps.

2. Look at how they are behaving.  A significant tummy pain will usually manifest itself in some way in the child’s posture, activity or interaction.  A child who walks in and plays but says they have severe pain may be proving my point about understanding and describing pain.

Next time you see a child and want to know about their pain.  Ask them in a way that allows them to say what they want to say, in the way that they want to say it.

Edward Snelson
@sailordoctor

Reference
John Finnemore, Cabin Pressure, BBC Radio Comedy

Non-specific abdominal pain and medically unexplained symptoms

In the early days of GPpaedsTips, I wrote about how I don't like to diagnose non-specific abdominal pain unless constipation has been ruled out.  I think that especially in the pre-teens, undiagnosed constipation is a big factor in mysterious abdominal pains.  In the child where such causes have been ruled out, it is curious that we have kept the term 'non-specific abdominal pain' (NSAP) or 'recurrent  abdominal pain' (RAP) when the label of 'medically unexplained symptoms' (MUS) fits just as well, if not better.

First of all, let's deal with the elephant in the room.  Medical terminology is always evolving and it is sometimes hard to keep up.  Many of us heard different terms used when we first studied medicine (such as functional or psychosomatic) for what seem to be the same clinical scenarios that are now labelled as MUS.  I don’t like perpetual re-labelling of problems. Medically unexplained symptoms, for me, is an exception to this dislike.  MUS removes the judgement of how much a problem is psychological and how much it is physical.  MUS acknowledges that there is always a combination of the physical and psychological.  How much of each component exists is neither measurable nor essential to know.  Is it 60:40 or 30:70?  I don’t know.

The other benefit of calling the situation MUS is that it recognises the possibility that an unknown physical cause may exist.  If a symptom has no medical explanation, the problem may be that medicine has failed to explain the symptom.  Although very few MUS scenarios end up with a eureka moment later on, a significant physical cause is sometimes found.

One definition of MUS is, "symptoms for which a treating physician or other healthcare providers have found no medical cause, or whose cause remains contested."(1)  When a young person presents with recurrent abdominal pains, once the physical medical causes have been ruled out, what we are left with is a medically unexplained symptom.  Labelling the scenario as NSAP is historical and has the potential to be revisited.

Is there anything wrong with the label of NSAP?  I can see two potential pitfalls, both of which arise from that way that it sounds a lot like a diagnosis.  The first problem is that both family and clinician may see the matter as closed.  This carries the risk that a diagnosis might be missed, especially if it is one that easily goes beneath the radar, such as coeliac disease.  This publication lists various pathologies that were found following a diagnosis of NSAP. (2)

Nor should we over-investigate.  As discussed in a recent review article on MUS in ADC (3), the problem here is the "impossibility of proving a negative."  Rather than give every child with abdominal pain an endoscopy, the middle way of leaving the diagnosis open while observing and looking for a recognisable pattern may be safer than labelling as NSAP.

The second problem is that any psychological component may not be addressed.  Is there a psychological component in NSAP?  I would say that there always is but for different reasons depending on the scenario.  The more physical the problem, the more distressing it is to have chronic symptoms that cannot be easily explained or be treated.  If the symptoms could be described as being secondary to a psychological cause, then the psychological component is self-evident.  There is no chronic abdominal pain scenario that I can think of that would not benefit from a dual physical-psychological approach.

I think that this dual approach is what tends to be done with NSAP already, whether it is managed by GP, paediatrician, gastroenterologist or surgeon.  An open minded and holistic approach is essential when managing medically unexplained abdominal pain in young people.


Managing medically unexplained abdominal pain in young people in Primary Care

In some cases, a cause of abdominal pain is obvious.  Common pathologies are constipation and reflux oesophagitis.  Both can be managed in Primary Care if there are no red flags and the problem responds to treatment.  Even when the cause is less obvious, the cause is often constipation, which is why it is worth really asking in detail about diet, bowel habit and the pain.  I also believe that a trial of macrogol laxatives is often a good strategy in the absence of an obvious cause.

In more extreme cases, there may be red flags such as weight loss, or bloody mucousy stools.  These children should be referred though an urgent route (inpatient or out-patient depending on the circumstances).  If the symptoms are severe enough to warrant immediate admission and investigation, laparoscopy finds a cause in about half of patients. (4)

There are also cases where there appears to be a psychological cause, often related to stresses such as school, bullying or even abuse.  It is still important to consider physical causes but there is nothing wrong with moving to address the psychosocial causes early on.

In some cases there is genuine ongoing uncertainty.  The usual pathway for these children is to refer to paediatric surgeons, paediatrics or paediatric gastroenterology for further investigation.  After this, clinical psychologists are often involved.  I don't know what they do.  Witchcraft or something.

Edward Snelson
@sailordoctor
Unexplained Medic

Disclaimer - If you can't explain it, it's not my fault.   You're clearly not trying hard enough.

References

1. Medically unexplained symptoms, Wikipedia
2. Sanders, D et al, A New Insight into Non-Specific Abdominal Pain, Ann R Coll Surg Engl 88(2); 2006 Mar
3. Cottrell, D, Fifteen-minute consultation: Medically unexplained symptoms, Arch Dis Child Educ Pract Ed 2016;101:114-118
4. Decadt, B. et al, Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain, British Journal of Surgery, Vol 86, Issue 11, pages 1383–1386, 1 November 1999